Procurement Portal

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World Class Commissioning Good Practice
Event Managing the Local Health System - Stroke
Rehabilitation 15th July 2009
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Team today

• Janet Fitzgerald - World Class Commissioning
  Programme Director
• Hilary Tyler - Deputy Chief Executive NHS
  Hampshire
• Jonathan Anscombe A.T. Kearney
  jonathan.anscombe_at_atkearney.com
• Neil Baguley A.T. Kearney

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South Central recognised that it needed to do
things differently, and was an early advocate of
the Health Market Analysis work
Notes Competency scores are derived by averaging
individual PCT scores
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South Central/A.T. Kearney/Stroke
Rehabilitation/Overview/15.07.09
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The approach we adopted for commissioning was
strategic sourcing a structured approach to
market management
Analysis and Prioritisation
Implementation
Strategy and Planning
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Market Profiling
Intervention Strategy
Stakeholder Testing
Implementation Planning
Intervention
Implement Change
Measure and Manage
Segmentation
Initial Assessment
Prioritisation
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Communication and Change Management
Outcomes achieved
Rigorous contract development provider
management
Deep dive analysis strategy formation
Broad high-level analysis prioritisation

• Common language and common view of the market
• Consensus of priorities based on
• Need for improvement
• Potential for market structure change
• Ease of implementation
• Clear next steps

• Detailed understanding of the segment and market
  potential
• Tested strategic options
• Consensus on the strategic approach
• Actionable implementation plan

• Clear signalling to the market
• Commercially robust contracts
• Strong, structured and consistent provider
  management
• Realisation of outcome improvement targets

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South Central/A.T. Kearney/Stroke
Rehabilitation/Overview/15.07.09
Source A.T. Kearney methodology
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Stroke was identified as a major health need,
with growing demand especially in most vulnerable
age group
Predicted Stroke Incidence(1)
Population Trend
34
29.0k
Total Stroke cases
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21.7k
Total Pop.
4.1m
3.7m
(14)
(11)
Over 69
Over 69
(86)
(89)
Below 69
Below 69
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South Central/A.T. Kearney/Stroke
Rehabilitation/Overview/15.07.09
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Different types of intervention were identified
as being required at different points along the
pathway
More loosely defined individualised patient
choice convenience important more potential
for innovation
Tightly defined requirements Speed and access
critical
Care Pathway
Diagnosis
Rehabilitation
Intervention
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South Central/A.T. Kearney/Stroke
Rehabilitation/Overview/15.07.09
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Stroke in Hampshire the need to focus on the
entire pathway

• Hampshire population healthy and demanding with
  pockets of inequality
• Rapidly aging population cant carry on with
  existing models of care
• Joint Strategic needs assessment
• Rising numbers of stroke patients
• Average outcomes for a healthy population
• Variable outcomes with no relationship to
  investment
• Care burden of existing model too high for health
  and social care
• Priorities
• Prevention Vascular inequalities case finding
  and brief interventions
• Rapid Diagnosis for high risk patients wherever
  you access the service
• (National priority thrombolysis)
• Acute Care to provide evidence based bundle of
  care (MINAP)
• Rehabilitation

More loosely defined individualised patient
choice convenience important more potential
for innovation
Tightly defined requirements Speed and access
critical
Care Pathway
Diagnosis
Rehabilitation
Intervention
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South Central/A.T. Kearney/Stroke
Rehabilitation/Overview/15.07.09
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We worked closely with our current providers to
introduce service change and improvement where
possible
Care Pathway
Diagnosis
Rehabilitation
Intervention
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South Central/A.T. Kearney/Stroke
Rehabilitation/Overview/15.07.09
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This approach is part of a commissioning cycle
and we need to review progress

• Prevention Vascular inequalities case finding
  and brief interventions
• Review weight management interventions for
  evidence of outcomes and effectiveness
• Rapid Diagnosis for high risk patients wherever
  you access the service
• Expand to weekends (tariff)
• (National priority thrombolysis)
• Acute Care to provide evidence based bundle of
  care (MINAP)
• CQUIN in use for 09/10 normative tariff for
  10/11
• Rehabilitation
• use market to deliver a different model of care
  manage consequences in acute setting

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South Central/A.T. Kearney/Stroke
Rehabilitation/Overview/15.07.09
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That initial broad assessment of the market
identified a clear need to improve Stroke Rehab
services
Context
Challenges

• Every year approximately 110,000 people in
  England have a stroke
• Stroke is the third largest cause of death in
  England 11 per cent of deaths in England are as
  a result of stroke
• A range of national initiatives, including a
  National Stroke Strategy has been published to
  address the significant need for improvement in
  the Stroke care pathway
• Across most of the NHS, a significant amount of
  work has gone into prevention, early diagnosis
  and treatment

• Need for improvement in post-Acute Stroke care
  has not been fully addressed
• Common issues include shortage of specialist
  skills, inequity and inconsistency of provision,
  lack of seamless transfer through care pathway
• Key market failures include high supplier
  concentration for inpatient care, fragmented
  community provision and financial disincentives
  across health and social care

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South Central/A.T. Kearney/Stroke
Rehabilitation/Overview/15.07.09
Source A.T. Kearney analysis
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We focussed efforts on Step Down and Home
rehabilitation
Care Pathway
Rehabilitation
Diagnosis
Intervention
Maintenance
Prevention
Patient fit for discharge acute rehab
At home Rehabilitation
Step Down Rehabilitation
Maintenance
Stroke co-ordinator
Facilities / site with multidisciplinary team
Stroke co-ordinator and multidisciplinary team

• Outpatient rehabilitation in the community,
  either through
• Specialised community stroke team (increasing
  through esd schemes)
• Generic rehabilitation team
• Fragmented and inconsistent
• 3rd sector and social services prevalent

• Provision either within
• Remaining in generic or acute stroke units
• Dedicated rehab beds within acute,
• Rehab stroke units within acute
• Rehab stroke beds or units within community
  hospital setting
• Other free-standing rehab stroke units
• Much current provision still within acute - high
  LOS here

Optimum Functional State
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Analysis identified an unrecognised requirement
for an 800 increase rehabilitation capacity
Number of Patients in 2007
3300
1990
Number of Patients in 2020(1)
2660

• Aging population
• Increase in conditions which lead to stroke
  diabetes, obesity
• Lower morbidity because of stroke (eg,
  thrombolysis)
• Government guideline for stroke rehab

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South Central/A.T. Kearney/Stroke
Rehabilitation/Overview/15.07.09
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A case for change was developed to address
current failures
Issues with Current Service Provision
Access

• Service coverage is poor
• Lack of domiciliary workforce in pockets of the
  country
• Widely fragmented provision
• No continuity of the provision as different
  people provide different services
• Lack of localised solutions for different areas

Efficiency / VfM

• Economies of scale are not exploited
• Higher Acute provider costs
• Also, longer LOS

• No definition of service specification (for both
  community and step down)
• Inconsistency of service provision for home based
• Poor integration with other services (education,
  social education, psychology)
• Lack of co-ordination of stroke patients within
  the community
• No support for early discharge

Quality
Choice

• Conflicts between patient choice of where it
  happens versus evidence of best outcomes
• Lack of long term arrangements for stroke rehab
  patients by Local Authorities
• Complexity due to the large number of acute
  providers
• Lack of diversity of community rehab centres
• Patient condition means many are not in a
  position to exercise choice

Capacity

• Insufficient operating hours
• Shortage of skilled resources

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Sources Region A workshops and PCT interviews
A.T. Kearney market analysis
South Central/A.T. Kearney/Stroke
Rehabilitation/Overview/15.07.09
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Current and potential providers of post-Acute
rehabilitation services were identified
Relative Importance
Relative Importance
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South Central/A.T. Kearney/Stroke
Rehabilitation/Overview/15.07.09
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Specific potential organisations were identified
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South Central/A.T. Kearney/Stroke
Rehabilitation/Overview/15.07.09
Source A.T. Kearney analysis, interviews, market
soundings
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Objectives for the new service were developed
through workshops
Improve Service Quality

• Consistency of provision
• Support the move toward community and home care

Introduce New Provider Options

• Creation of commercially attractive bundles for
  suppliers
• Leverage non-Acute providers

Improve Access

• Broaden access to specialist services for
  patients /carers

Improve Co-ordination

• Locally tailored delivery model
• Seamless and timely service integration
• Co-ordination with ancillary services
• Co-ordinate with primary and secondary care
• Consider a whole-system approach

Manage capacity

• Mitigate projected capacity constraints in the
  market
• Leverage technology solutions

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South Central/A.T. Kearney/Stroke
Rehabilitation/Overview/15.07.09
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13 potential solutions were identified, with two
options selected as having the best fit with
local requirements
At Home Rehabilitation
Step Down Rehabilitation
1 A continuum of care for the patient across
sub-acute, community and home-based health
services
Bundling
2 Coordination of longer term rehab element
3. Unbundle and commission for a Psychology
service across the pathway
4. Vocational rehabilitation package
Unbundling
5. Commission generic rehab separately and bundle
with other conditions
6 Unbundle home adaptation and equipment
provision and put to competitive tender
7. Invite alternatives to traditional resource
intensive model of rehab to incl. new web based
telemed. technologies
Alternative Service Models
8. Commission services to support self care
9. Commission a screening, coordination service /
data system to also involves primary care and
ancillary services
10. Commission for transitional care package
11. Commission a coordinator role or
integrator to provide link and training to all
other services ancillary
New Services/ Roles
12. Commission a stroke specialist to train
providers
13. Support organiser roles e.g. dysphasia
support as complementary to the core stroke
specialist SLT therapists
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Notes Region A Stroke Rehab Workshop PCT
interviews A.T. Kearney Analysis
South Central/A.T. Kearney/Stroke
Rehabilitation/Overview/15.07.09
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Service packages and, where relevant, tender lot
combinations were then defined
Potential Lots

• Information provider across pathway
• suppliers offering data system and/or service
  that enables the right patients to understand and
  access all available post-acute rehab services,
  at the right time
• Access to life
• suppliers offering assessment, home adaptations
  and links to ancillary services
• Training providers and working life
• patients as trainers for providers, patients or
  carers combined
• Emotional support with SLT across pathway
• embedding psychology through innovative
  alternative delivery models e.g. peer led, groups
  
• Co-ordination with assessment/monitoring
• coordinator assessing patients to include long
  term reviews
• Psychology with training
• counsellors providing training to providers and
  carers to upskill and partially close the
  capacity
• Multi-disciplinary stroke team
• applying systems, staffing and routines of ward
  to provide case management virtually

Co-ordinator Service
Information Provision
Step Down
At Home
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Source A.T. Kearney
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The Commissioning strategy allowed for local
implementation and evolution towards the desired
market solution
Stages of Evolution (SOE) Stroke Rehab
Key Characteristics
Service Gaps Failures
Core Standards
Partly Integrated
Continuum of Care
Stage 1
Stage 2
Stage 3
Stage 4
Service State
Supply Market State

• Major service gaps and failures - e.g.
  specialist clinical skill shortage, inconsistent
  coordination, etc
• Near monopoly situation with broader market
  options unexplored. Little/no community data
• Separation of health and social care

• Service failures addressed for the core
  requirements in SD and at Home - e.g. SLT,
  integrated MDT across SD and Home
• Expanded number of providers. At Home data
  available
• Unbundled tariff for different elements of care

• At Home gaps filled through coordination service
• Move to single providers coordinating each of SD
  and At Home markets
• Pooled funding across health and social care -
  bundling out of stroke specific services from
  other community services

• All service gaps filled or failures addressed
• Single provider managing the whole pathway
  possible lead contractor model
• Individualised budgets funds allocated for
  tailored range of services at an individual
  patient level

Commissioning State
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South Central/A.T. Kearney/Stroke
Rehabilitation/Overview/15.07.09
Source A.T. Kearney
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Across South Central, we are putting in place an
innovative new operating model which will enable
us to collaborate more and better undertake our
commissioning activities
Working in Partnership - internally
South Central PCTs new way of working The
Collaborative Operating Model (COM)

• Our Collaborative Operating Model will deliver
• Improved quality and outcomes for people in our
  communities
• Improved cost effectiveness

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South Central/A.T. Kearney/Stroke
Rehabilitation/Overview/15.07.09
Source South Central Alliance
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Rehabilitation/Overview/15.07.09
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Topics for discussion

• Is competition unavoidable in the projected
  budgetary climate?
• Competition versus cooperation
• When is it okay to compete?
• At what point, and from which triggers, do you
  stop trying to galvanise the current provider to
  change?
• What gets in the way from doing this well
  understanding? Capability? Capacity? Other?
• How do you engage the local community to bring
  them with the chosen solution?
• Others?

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South Central/A.T. Kearney/Stroke
Rehabilitation/Overview/15.07.09